5.3 Assessing breastfeeding
The five-step process
- Gather information and plan for the visit
- Feeding observation
- Exploration of strategies for improvement
- Develop an action plan
- Communication of results
1. Gather information and plan for the visit
Review pertinent information including mother's/infant's chart, notes from telephone conversations, notes from referral source, etc, prior to meeting with the mother and infant.
Planning includes assembling any items and equipment you expect to use during the assessment (eg. comfortable chair for mother, infant scale, etc.).
2. Feeding observation
- General observation: general interaction between the mother and infant. Health of mother, health of baby, health of the mother's breasts.
- Naturalistic observation: observation of a portion of a usual breastfeeding. This is best performed without intervention from the assessor.
- Elicited observation: observation of the outcome of suggested modifications (eg changes to position, attachment, etc.).
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![]() | ![]() Use your communication skillsIt can help to put the mother at ease if you explain that you would like to watch the baby feeding, rather than saying you are watching what the mother is doing. And don't forget to praise the mother for something she is doing that is good.
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What is involved in a 'naturalistic observation'?
Mother's and baby's position
- Do the mother and baby appear comfortable and relaxed?
- Is the baby well positioned?
- Good sensory input: breast wasn't washed prior to feeding; baby in firm contact with mother chest-to-chest, either no clothing or minimal clothing between them.
- Good positional stability: a stable base; proximal stability; midline symmetry
Latching
- Did mother position baby, then allow baby to latch himself? If not, why not? eg. breast may have needed to be shaped; is the mother controlling the baby's latching?
- Where is baby's chin? Is it firmly applied to the breast? Is the baby's nose free to breathe without the need to hold the breast tissue away? Exceptions only with very large, soft pendulous breasts.
- Is baby's mouth very wide open with both lips flanged outwards? Exceptions to this are in mothers with soft, elastic breast tissue where a baby can achieve a deep latch with lots of breast tissue and not need to continue the wide gape throughout the feed.
- Can you see more areola visible above the top lip than beneath the bottom lip (or, if areola small, another sign that the baby has a large amount of breast tissue in mouth).
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![]() | ![]() Really important!One author 2 viewed the positioning and latching procedures adopted by mothers with painful nipples and concluded that the whole process from pre-feeding behaviors to the suck rhythm need to be assessed.
Observe the moment of latching of the baby to the breast and as much of the feed as you can, then be there again to observe the nipple as it leaves baby's mouth. | ![]() |
Sucking pattern
- When first latched was sucking rapid for up to a minute? This is a stimulation pattern to elicit the milk ejection reflex.
- After about a minute (or less) did sucking settle into a regular, slower suck/swallow/breathe/suck/swallow/breathe pattern with some short pauses? This is a nutritive sucking pattern. You may hear baby swallowing milk; milk may leak from the other breast; or mother may report feeling the milk ejection reflex.
- What are baby's jaw movements like? They should be 'deep' movements visible right up to the temporo-mandibular joint below the ears.
- How long did the nutritive sucking pattern persist? Milk ejection usually lasts about 2 minutes and therefore the nutritive sucking pattern should last about that long.
- What happened after the nutritive sucking pattern stopped? Sucking usually returns to the short, quick stimulation pattern again with smaller jaw movement, fewer swallows and longer resting pauses.
- Was the nutritive pattern repeated? It doesn't have to be, but this cycle may be repeated as baby stimulates a second or more milk ejections during one breastfeed.
How was the breastfeed completed?
- Did the baby fall asleep at the breast being completely satiated, or detach himself contented, or wanting more milk from the other breast, or did the mother remove the baby when she felt he'd had enough?
What did the nipple look like as it came out of the baby's mouth?
- Observe the nipple immediately when it comes out of the baby's mouth. It should look very similar to its pre-feeding state. There should be no ridges or 'squashed' appearance or white compression lines.
How did it feel?
- Of course you will ask the mother how it feels at each stage, and also observe her for signs of anxiety or pain.
- In the first few days for the first minute or less she may describe it as painful, but settles to be pain free quickly. This initial pain is called 'nipple stretch pain' and occurs as the nipple and areola form the teat. Breastfeeding may 'tug' but for the majority of mothers it should not be painful.
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![]() | ![]() Workbook Activity 5.6Complete workbook activity 5.6
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![]() | Observation skillsLook closely at these photos, noting all the details of positioning and latch.
When you are ready, answer the response activity below. ![]() | ![]() |
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3. Exploration of strategies for improvement
- The development of hypotheses for improving the feeding interaction based on history and observations.
- Discussion with mother of hypotheses generated, including pros and cons of various methods for improving the feeding outcome.
- Testing of agreed strategies.
4. Develop an action plan
Record this in the mother's file and give a copy to the mother or write a list for her to refer to at home.
5. Communication of results
- Reiterate findings and action plans for the mother. The language used to describe the situation is extremely important. The assessor should take great care to avoid terminology that blames, negatively characterizes, or labels the mother or infant.
- After learning new skills of how to position her baby to overcome previous breastfeeding difficulties the mother sits and cradles her baby as he feeds and explains to the consultant how she positioned her baby. Cox (2011)3 contends that the consultant is then able to be confident that this mother and baby will now be independent as she has:
- watched the mother position, as suggested, so that the baby could latch comfortably
- written down, in the mothers words, how she positioned her baby
- Document the outcomes of the assessment and evaluation.
- Review plans with the mother to assure that the plan is achievable and agreeable to all parties.
- Communicate findings to key healthcare providers in accordance with mother's consent to release information. Clearly identify and refer any items that need further medical evaluation.1
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Look carefully at this baby breastfeeding and complete the response activity below.
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![]() Workbook Activity 5.7Complete Activity 5.7 in your workbook. |
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![]() Make your work easy!When a mother quickly becomes confident positioning her baby and facilitating his latch baby will be fed well, nipple and breast problems prevented and your workload will be reduced. |
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What should I remember?
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Assessment Quiz
Notes
- # Wolf LS et al. (1992) Assessment and Management: Feeding and Swallowing Disorders in Infancy
- # Blair A et al. (2003) The relationship between positioning, the breastfeeding dynamic, the latching process and pain in breastfeeding mothers with sore nipples.
- # Cox SG (2011) Planning with the mother to overcome breastfeeding difficulties - manuscript pending publication.